Inspection on 08/12/05 for Walmer Lodge

This inspection was carried out on 8th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Walmer Lodge 25/10/07

Walmer Lodge 20/03/07

Walmer Lodge 20/09/06

Walmer Lodge 05/05/05

Walmer Lodge 26/11/04

Walmer Lodge 09/06/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood Hall

Muston Road (70)

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Walmer Lodge 6 Walmer Villas Manningham Bradford West Yorkshire BD8 7ET Lead Inspector Steve Marsh Unannounced Inspection 09:30 8 December 2005 th Walmer Lodge DS0000001222.V264636.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Walmer Lodge DS0000001222.V264636.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Walmer Lodge DS0000001222.V264636.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Walmer Lodge Address 6 Walmer Villas Manningham Bradford West Yorkshire BD8 7ET 01274 499338 01274 499338 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Suleman Ahmed Chunara Mr Sikander Khan Mr Salihu Tifin Shehu Care Home 12 Category(ies) of Learning disability (12), Mental disorder, registration, with number excluding learning disability or dementia (12) of places Walmer Lodge DS0000001222.V264636.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Walmer Lodge is situated in the Manningham area of Bradford, approximately one mile from the city centre. The home is on a main bus route, and both Bradford and Keighley can be easily reached by public transport. The home is registered to care for twelve service users with either mental health problems or learning difficulties in single bedroom accommodation. There is no disabled access to the building or passenger lift to the bedrooms on the upper floors, therefore the home would not be suitable for service users with physical disabilities. There is a small garden to the front of the property and a car park to the rear, although the access is quite narrow. Walmer Lodge DS0000001222.V264636.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced inspection for the year 2005/06, and was carried out by one Inspector over a period of approximately eight hours. The last inspection was in April 2005 and the main purpose of this visit was to assess the home’s progress in meeting the requirements from the last inspection. The methods used during this inspection included the examinations of records, observation of care practices, discussion (group and individual) with service users, staff and management and a partial tour of the premises. Comment cards were left at the home to provide the service users and visitors with the opportunity to share their views of the service with the Commission. Feedback was given to Mr Shehu (registered manager) at the end of the visit. Requirements made during this visit or outstanding from previous inspection visits are at the end of this report. What the service does well: What has improved since the last inspection? The manager continues to ensure that staff receive the training and support they require to meet the needs of the service users, and formal staff supervision is now carried out at least six times a year. Walmer Lodge DS0000001222.V264636.R01.S.doc Version 5.0 Page 6 The manager has achieved a recognised management qualification and some staff are now studying for a National Vocational Qualification (NVQ) at level two. The home has a training plan in place for 2006, which indicates the manager’s commitment to have a trained and experienced staff team. A quality assurance survey was carried out in June 2005, and it is anticipated that this will now be done at least annually. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Walmer Lodge DS0000001222.V264636.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Walmer Lodge DS0000001222.V264636.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,4,5 Service users and/or their relatives are provided with sufficient information to enable them to make an informed decision about the home. The admission procedure is thorough and includes pre-admission assessment visits, introductory visits and trial periods. EVIDENCE: The manager confirmed that there have been no changes to the home’s statement of purpose or service user guide since the last inspection. All admissions continue to be planned. The manager visits all prospective service users prior to admission. The needs identified during this visit are reflected in their initial care plan. The manager confirmed that he is aware of the limitations of staff in dealing with service users with complex mental health needs, and will not admit a service user unless he feels the home can provide the level of care/services they require. Records reviewed showed that the cultural and religious beliefs of service users from ethnic minority groups are taken into account, and a number of staff are fluent in Asian languages. In addition to pre-admission assessment visits, prospective service users are invited to visit the home prior to admission, to view the accommodation, meet Walmer Lodge DS0000001222.V264636.R01.S.doc Version 5.0 Page 9 the other service users and members of staff, and stay for a meal if they wish to do so. All service users are initially admitted to the home for a three-month trial period following which a review meeting is held to discuss the placement and plan their future care. Service users are provided with a contract/terms and conditions of business on admission to the home as required. Walmer Lodge DS0000001222.V264636.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9,10 Care plans are completed to a good standard, and clearly indicate that the service users participate in the care planning process. Staff encourage and support service users to make decisions about their daily lives and routines. EVIDENCE: Care plans are in place for all service users and records showed that they continue to be reviewed on a three monthly basis by the service user, their key worker and manager. Risk assessments have also been completed for each service user highlighting areas of potential risk, which may limit their freedom of choice and/or affect their quality of life. The manager confirmed that service users are encouraged to make as many decisions as possible in relation to their daily lives. At present the staff are supporting one service user who wants to live back in the community. To assist the service user to make this move the home are liaising with other professionals involved in his care to ensure the risks involved are minimised. Walmer Lodge DS0000001222.V264636.R01.S.doc Version 5.0 Page 11 Service users are encouraged to manage their own financial affairs, however members of staff will assist/support them if requested to do so. Staff/service user meetings continue to be held on a regular basis, and the service users spoken to, said that they were kept informed of any changes to the homes policies and procedures, which directly affect the standard of care/services provided. As required in the last inspection report the service users have been provided with a copy of the homes policy on confidentiality, and the manager confirmed that he ensures they have not only received the information but also understand it. Walmer Lodge DS0000001222.V264636.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17 In house activities appear limited, however service users are encouraged to participate in activities outside the home, and maintain strong links with their family and friends. EVIDENCE: The manager confirmed that wherever possible the service users are given the opportunity to participate in the activities they enjoyed prior to moving into the home and this information is recorded in their care plan. Service users have limited involvement in the daily domestic routines of the home, although with staff support they are encouraged to clean their own bedrooms and do some laundry tasks. Due to the lack of suitable facilities the service users are not involved in preparing meals, however there is a kettle available in the dining room to enable them to make tea or coffee if they wish to do so. Service users described the meals provided as good and confirmed that an alternative was always offered if they did not like what was on the menu. Walmer Lodge DS0000001222.V264636.R01.S.doc Version 5.0 Page 13 At present no service users are in paid or voluntary employment although five service users regularly attend day centres during the week. Service users confirmed that they continue to visit the shops, cinemas, pubs etc in the local area and participate in community events whenever possible. Outings are also arranged either on an individual or group basis and a number of service users said that they had enjoyed a day trip to Scarborough during the summer. A trip to Amsterdam had however not gone ahead as planned, although the manager was hopeful that this would be rearranged for sometime in 2006. Activities within the home appear limited, however entertainers recently visited the home and performed live music, and it is now anticipated that this will occur on a more regular basis. Families and friends are welcome to visit the home at any time and the service users spoken to confirmed that they are able to see visitors in their own rooms if they wish to do so. A number of service users stay with their family at the weekends, which enables them to maintain contact and socialise with people who do not have a disability. Service users are provided with keys to their bedroom, however for security reasons it is not felt appropriate for them to have a key to the main door of the property. Walmer Lodge DS0000001222.V264636.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 20 Service users receive care and support in a manner, which respects their different cultural and/or religious beliefs. EVIDENCE: Service users confirmed that the daily routines of the home are flexible and they are able to go to bed/get up, have a bath etc whenever if they wish to do so. However, for service users attending day centres it is acknowledged that during the week there has to be some structure to their day. To support them in maintaining their quality of life the home operates the key worker system, with each service user being designated a member of staff usually from the same cultural, religious background or the same gender. Service uses spoken to say that they felt well supported by their key workers and had a good relationship with them. The home continues to use a monitored dosage system of administering medication (blister pack), which is securely stored on the premises. Walmer Lodge DS0000001222.V264636.R01.S.doc Version 5.0 Page 15 On checking the medication held at the home against the medication administration record (MAR) sheets, no concerns were raised and all medication appeared to have been administered as prescribed. Walmer Lodge DS0000001222.V264636.R01.S.doc Version 5.0 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 The adult protection procedures in place ensure that service users are listened to, and protected from any form of abuse. EVIDENCE: Policies and procedures are in place at the home in relation to adult protection and appropriate training has been made available to staff. As required in the last inspection report the manager has recently attended a Social Services adult protection-training course and will now take on the role of trainer. Staff spoken to said that they were aware of the homes policy on “whistle blowing” and their responsibility to protect the service users from any form of abuse. Walmer Lodge DS0000001222.V264636.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,26,27,2829,30 The home provides a satisfactory standard of accommodation although some areas would benefit from decorating or generally brightening up. The standard of cleanliness in the communal toilets and bathrooms/shower rooms was again poor placing service users at risk. EVIDENCE: The home provides a satisfactory standard of accommodation for the service users, although some areas of the property would benefit from decorating to make them brighter and more welcoming. The communal rooms used by the service users are situated on the ground floor of the property and consist of a lounge, dining room and a smoke room. There is also a small quiet lounge/library room next to the manager’s office, which can be used by service users, but is also used by staff providing the sleep-in cover. There is no disabled access to the home and no passenger or stair lift to the bedrooms on the upper floors of the property, which makes it unsuitable for service users with physical disabilities. Walmer Lodge DS0000001222.V264636.R01.S.doc Version 5.0 Page 18 Bedrooms are situated on all three floors of the home, and in addition to the en-suite facilities there are also communal toilets and bathrooms/shower rooms throughout the building. Approximately 50 of the bedrooms were reviewed during the visit and in general the rooms are decorated and furnished to satisfactory standard. However, a bedroom on the top floor of the building requires decorating as it appeared very dark and unwelcoming. The carpet in another bedroom on the same floor also requires cleaning or replacing as it is badly stained. The standard of cleanliness in all communal toilets and bathrooms/shower rooms was poor, and the shower rooms in particular would benefit from a thorough clean and/or decorating. There was no soap in the laundry room where personal clothing and bedding is handled, and the wash hand basin was dirty. Walmer Lodge DS0000001222.V264636.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36 Service users are supported and protected by a robust staff recruitment and selection procedure, which includes Criminal Record Bureau (CRB) checks. The manager must ensure that senior members of staff are clearly identified on the duty rota. To safeguard the service users the manager must review the cleaning hours, as it is obvious that they are not sufficient to keep the home clean. EVIDENCE: The manager confirmed that the home is fully staffed at the present time and that staffing levels are adequate to meet the needs of the service users. However, the rota for the week of inspection indicate that there was no designated senior member of staff on duty over the weekend period, which had also been the case on the last inspection visit. The manager confirmed that there were staff working at the weekend who had the experience and skills to manage the home, but acknowledged that they should be designated as senior staff and recorded as such on the rota. Walmer Lodge DS0000001222.V264636.R01.S.doc Version 5.0 Page 20 Due to the poor standard of cleanliness and hygiene in the communal toilets and bathrooms/shower rooms the manager must review the cleaning hours, as it is apparent that they are not sufficient to keep the home clean. As this was also highlighted in the last inspection report the manager must now take urgent action to address the matter. The personnel files of one recently employed member of staff, and three existing staff were reviewed, and it was evident that home’s recruitment and selection procedures are thorough. The manager confirmed that the home had tried to get service users to become involved in the recruitment of new staff by showing prospective applicants around, however there had been a reluctance on their part to do so. All staff receive induction and foundation training, and the training plan for 2005/06 clearly indicates that additional training both to meet the needs of the service users and for personal development is encouraged. There is also an expectation that staff will study for a NVQ at level two (or equivalent), and at present four staff are studying for the qualification. In addition, two staff have already achieved NVQ level two or three and one of the senior staff is presently studying for a NVQ at level four. The manager confirmed that individual staff training needs are discussed during their formal supervision, which is now held at least six times a year. Walmer Lodge DS0000001222.V264636.R01.S.doc Version 5.0 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,42 The manager is competent and has shown a willingness to work with the Commission for the benefit of the service users. The views and opinions of the service users are sought and wherever possible they are involved in the decision making process. EVIDENCE: Since the last inspection visit the manager has achieved a recognised management qualification, and continues to undertake periodic training to update his knowledge/skill base. Staff confirmed that the manager has an open and approachable management style and ensures that the service users are cared for appropriately. Service users also confirmed that the manager and staff were friendly and throughout the visit there was a lot of friendly banter and social interaction between the service users and staff. Walmer Lodge DS0000001222.V264636.R01.S.doc Version 5.0 Page 22 Daily handovers between morning, afternoon and night staff take place and regular staff/service users meetings ensure clear channels of communication within the home. The manager confirmed that quality assurance questionnaires were sent out to service users, relatives and professionals i.e. social workers etc in June 2005 and the home had received a reasonable response. The feedback from service users and/or relatives was in general positive and no concerns were raised. However mixed comments were received from professionals accessing the service. Some indicating that the home provided a good standard of care, while one in particular felt that both the standard of accommodation and service needed to be improved. The manager was reminded that the results of the survey should be published and made available to all interested parties including the Commission. Policies and procedures are in place to ensure the health and safety of the service users, visitors and staff, and it is the manager responsibility to keep them up to date. All staff receive mandatory fire training and both the fire alarms and emergency lighting are tested weekly. However, the date of the last fire drill was not recorded in the fire register and this must be addressed. Walmer Lodge DS0000001222.V264636.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 X 3 3 Standard No 22 23 Score x X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x 2 1 3 x 1 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 2 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Walmer Lodge Score 3 x 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 3 x x 2 x DS0000001222.V264636.R01.S.doc Version 5.0 Page 24 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA26 Regulation 23(2)(d) Requirement The top floor bedroom (identified to manager) requires decorating. The carpet in the top floor bedroom (identified to manager) requires cleaning or replacing. The registered manager must ensure that the communal toilet and bath/shower facilities are thoroughly cleaned and/or decorated. The registered manager must ensure that the wash hand basin in the laundry room is cleaned and soap made available. The registered manager must ensure that the duty rota clearly indicated senior members of staff. The registered manager must review the cleaning hours at the home to ensure they are adequate. (Outstanding from last inspection report previous timescale not met). The registered manager must ensure that all fire drills are recorded in the fire register. Timescale for action 31/03/06 2 YA27 23(2)(d) 28/02/06 3 YA30 13(3) 08/12/05 4 YA33 18 28/02/06 5 YA42 23 (4) 28/02/06 Walmer Lodge DS0000001222.V264636.R01.S.doc Version 5.0 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA32 Good Practice Recommendations The home should ensure that a minimum of 50 of the care staff team is qualified to NVQ level two or above. Walmer Lodge DS0000001222.V264636.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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